Online Defensive Driving Course Registration

Name

First Name*

Middle Name

Last Name*

Previous Name

Address

Address*

City*

State*
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip*

County*

Contact Information

Email*

Demographic Info

Birth Date*

Gender*  
Male
Female

Are you Hispanic or Latino (or are you of Spanish Origin)?* 
Yes
No

Are you from one or more of the following racial groups? (Select all that apply)* 
Asian
American Indian or Alaskan Native
Black or African American
White
Native Hawaiian or Other Pacific Islander
Choose not to Respond

Identify Primary racial/ethnic group*
Asian American Indian or Alaskan Native Black or African American Hispanic or Latino White Native Hawaiian or Other Pacific Islander Choose Not to Respond

Are you in the United States on a Visa - Nonresident Alien* 
Yes
No

If yes provide Home Country of Origin

Highest Degree*
Non/Less than H.S. GED High School Diploma Certificate Associate Bachelor's Doctoral First Professional Other Some College Unknown

Citation Information

Citation Date (mm/dd/yy)*

Citation/Complaint Number*

County Citation Issued*

Completion Date*

Drivers License Number*

Issuing State of Drivers License*
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Were you court ordered to complete this course?* 
Yes
No

If you chose to avoid a conviction by taking a Defensive Driving Course, select the best day/time and location for your class?*
Charleston-Weeknights 5:00 p.m. - 9:00 p.m. Effingham-Wednesday 6:00 p.m. - 10:00 p.m. Effingham-Saturday 8:00 a.m. - 12:00 p.m. Effingham-Saturday 1:00 p.m. - 5:00 p.m. Mattoon - Weeknights 5:00 p.m. - 9:00 p.m. Sullivan-Weeknights 5:00 p.m. - 9:00 p.m. Online

Submit

Once you submit your registration form, you will be responsible for the fee associated with the class you chose.

If you have chosen to participate in the classroom course, you will receive a class confirmation letter in the mail in 5-7 business days. If you have chosen to participate in the online course, you will receive an email confirmation soon. If you are submitting your online course registration form after business hours, you will receive your confirmation email on the next business day.